Provider Demographics
NPI:1992322838
Name:BUBP, STACI (FNP)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:BUBP
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 PARK WEST BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4311
Mailing Address - Country:US
Mailing Address - Phone:865-331-7975
Mailing Address - Fax:
Practice Address - Street 1:9330 PARK WEST BLVD STE 302
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4311
Practice Address - Country:US
Practice Address - Phone:865-331-7975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27756363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ061616Medicaid